Written to compliment a JAMA research paper on the same topic (reviewed by your Disease Management Care Blog here), this short manuscript uses fawning policy-speak that puts the creation of the PCMH on the same level as the discovery of penicillin and the defeat of managed care.

Knowing that many DMCB readers likewise share in the unquestioning admiration for the PCMH, the DMCB is pleased to offer this compact summary of the JAMA article using handy rhetoric that can be deployed at any time against a skeptical actuary, a cost-cutting Republican or a hell-no-we-won't-pay insurance executive. Simply shake vigorously and spray in the direction of that offending nuisance:

Primary care in the United States is in disrepair. Other countries that have primary care systems based on patient centeredness of the PCMH benefit from higher quality and lower costs. Promising studies of the PCMH have all but proven that it is associated with downstream savings, which should be enough to justify payment. What's more, the concept has been endorsed by the World Health organization and the Institute of Medicine. The PCMH is also at the forefront of value vs. volume payment reform, investing in better health for the nation, overcoming disparities and increasing access to care for vulnerable and underserved populations. That's why Federal government action that builds on the promise of the Affordable Care Act in the form of 1) additional demonstrations, 2) Medicare reimbursement for care coordination and 3) regulation of ACOs to assure incorporation of the PCMH is necessary.

And in the interest of fairness for all the PCMH skeptics, here's what you can say back:

Primary care is simply struggling to demonstrate value to health care consumers who, when given achoice, prefer specialists' care. Other countries' culture, governance and socioeconomics could account for much of their success with primary care and that's why there is no guarantee that simply importing it to the U.S. will prove to be a health care panacea. While there have been multiple PCMH studies, not one (in contrast to other population-based interventions) has demonstrated statistically significant savings, meaning that any observed savings could have been the result of random variation. While endorsement by WHO and the IOM are impressive, Americans have a prickly unwillingness to take large institutions' word for it and this is unlikely to have any impact on patient buy-in. Too many patients and doctors know that the terms "Federal" and "action" are not only contradictory, they confer a faith in government (as well as the ACA) that is not shared by a significant percentage of the very people that are supposed to benefit from the PCMH. Last but not least, looming "Taxmeggedon" makes it improbable that our politicians will embrace the notion of investing today's hard dollars for tomorrow's ephemeral savings. Until multiple studies in multiple settings consistently show savings vs. a valid comparator, the PCMH should remain a topic of research.

2 comments:

great post- there is a small editing mistake : "While (THERE) have been multiple PCMH studies, not one (in contrast to other population-based interventions) has demonstrated statistically significant savings, meaning that any observed savings could have been the result of random variation.

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About Jaan Sidorov MD, MHSA, FACP

While his web persona has been described as a "blogvocateur," Dr. Sidorov has wide range of knowledge about the medical home, condition management, population-based health care and managed care that is only exceeded by his modesty. He has been quoted by the Wall Street Journal, Consumer Reports and NPR’s All Things Considered.
He has over 20 years experience in primary care, disease management and population based care coordination. He is a primary care general internist and former Medical Director at Geisinger Health Plan.
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